The number of serious events at DHBs has risen by 4 per cent from 2012/13, which commission chairman Professor Alan Merry said was a "slight increase".
Repeatedly in the commission's serious-event publications, Professor Merry has stated that the quality of reporting by DHBs is improving.
The Herald asked if it was now good enough to assess trends from year to year.
He said such comparisons were not statistically valid because of the subjective judgments that had to be made by health services on what constitutes a "serious" event.
The important thing was that health workers engaged with the system so that lessons could be learned.
The place for year-to-year comparisons, he said, was in the commission's more narrowly focused harm-reduction programmes such as in hand hygiene and the surgical checklist. He also emphasised that the number of serious events was a tiny proportion of the around 3 million healthcare interactions people had with their public hospitals each year.
As in previous years, falls were the standout cause of serious events in 2013/14. "Ninety-eight people suffered a broken hip in hospital," said Professor Merry.
"This rate of harm is far too high and equates to almost two patients every week suffering such an injury.
"This is very disappointing given the considerable effort going into reducing harm from falls and shows this must continue to be an area of high priority for the commission and the sector."
Auckland DHB said 37 of its patients suffered serious harm from falls in 2013/14. One died as a result of the fall, 23 suffered fractures, five suffered serious head injuries, seven had lacerations requiring sutures, and one suffered a shoulder injury.
Describing one way it tried to reduce harmful falls, the DHB said it had started using "sticky sox" - socks with a grip sole - last December. None of the patients using the socks had had a fall causing serious harm.
Serious DHB problems
Waitemata District Health Board
• A newborn died in a water-birth.
• A mother bled to death at home following a birth.
• A newborn inhaled meconium (fetal poo), had air in the space around the lung and had a stroke during labour/birth. The DHB says the guidelines for fetal heart-rate monitoring "did not include duration required of monitoring for reduced fetal movements".
Auckland
• A dental patient was taken to the wrong operating theatre and anaesthetised for hernia surgery. The error was detected in time and the correct dental treatment done.
• A patient died following delays in diagnosis of meningitis. The case involved an "unusual clinical presentation" and "hand-over issues" between the emergency department and the inpatient team. It was uncertain if earlier antibiotic treatment would have saved the patient.
• Four women had foreign bodies left inside them - in three cases a swab - during obstetric or gynaecological treatment.
Counties Manukau
• A newborn suffered lack of oxygen after monitoring results were misinterpreted and birth was not expedited. There was a delay in recognising signs of uterine rupture. The mother needed a hysterectomy following the birth.
Southern
• A patient died after surgery, possibly because of a bed not being available in intensive care.
• A psychiatric patient with motor-skill problems choked on food and later died.
Bay of Plenty
• Death from blood infection following delay in recognising perforation of the small bowel.
Capital & Coast
• Incomplete observations were made of a cardiac patient and a clinical review was thought necessary but did not happen. The patient was transferred to intensive care and died of cardiac arrest.
Nelson Marlborough
• Stroke patient died after being given wrong clot-busting drug.
West Coast
• A newborn couldn't be resuscitated after emergency caesarean. Guidelines were later found to be unclear about how long a baby's heart rate should be machine-monitored before and after medicines are given to the mother to bring on birth. All maternity staff will undergo training in electronic fetal monitoring.
